NCLEX Examination.
Practice Question # 836.
nclex examination.
Actions to Take in the Emergency Department for a Client With a Burn Injury
- Assess for airway patency.
- Administer oxygen as prescribed.
- Obtain vital signs.
- Initiate an intravenous (IV) line and begin fluid replacement as prescribed.
- Elevate the extremities if no fractures are obvious.
- Keep the client warm and place the client on an NPO status.
The primary goal for a burn injury is to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore the priority action is to assess for airway patency and to maintain a patent airway. The nurse then prepares to administer oxygen.
The type of oxygen delivery system is prescribed by the physician. Oxygen is necessary to perfuse tissues and organs. Vital signs should be assessed so that a baseline is obtained, which is needed for comparison of subsequent vital signs once fluid resuscitation is initiated.
The nurse then initiates an IV line and begins fluid replacement as prescribed. The extremities are elevated (if no obvious fractures are present) to assist in preventing shock. The client is kept warm (using sterile linens) and is placed on NPO status because of the altered gastrointestinal function that occurs as a result of the burn injury. A Foley catheter may be inserted so that the response to the fluid resuscitation can be carefully monitored. Once these actions are taken the nurse performs a complete assessment, stays with the client, and monitors the client closely. Additionally, tetanus toxoid may be prescribed for prophylaxis.
